Essential Health Benefits: What Does Your Plan Really Cover?

When shopping for a health insurance plan, one of the most critical factors to consider is the range of services covered. Since the Affordable Care Act (ACA) came into effect, insurance plans are required to cover ten “Essential Health Benefits.” However, the specifics can vary from plan to plan and state to state. Here’s a rundown of what Essential Health Benefits generally include and what you should know to make the most out of your insurance plan.

1. Ambulatory Patient ServicesThese are the outpatient services you receive without being admitted to a hospital. It can include visits to the doctor, minor surgeries, and same-day medical care.

2. Emergency ServicesYour plan will cover services provided in an emergency room, but it’s crucial to understand the fees you might be responsible for, especially when treated at an out-of-network facility.

3. HospitalizationThis includes surgeries, overnight stays, and other services you’d receive if admitted to a hospital. However, you should check for any limitations, such as the number of covered days.

4. Maternity and Newborn CareCoverage starts from prenatal care and extends through childbirth and postnatal care. It also includes care for newborns, although the specifics can vary.

5. Mental Health and Substance Use Disorder ServicesThis includes behavioral health treatment, counseling, psychotherapy, and even substance use disorder treatment. However, the number of covered therapy sessions may be limited.

6. Prescription DrugsWhile most plans cover prescription medications, the extent of coverage can vary widely. There might be different tiers of drugs with varying costs to you, so check your plan’s drug list (formulary).

7. Rehabilitative and Habilitative Services and DevicesThese services aim to help individuals recover skills lost due to injury or a medical condition. Habilitative services help people acquire new skills due to developmental issues.

8. Laboratory ServicesMost preventive lab tests are covered, but you may have to pay for diagnostic tests.

9. Preventive and Wellness ServicesThis includes routine check-ups, patient counseling, screenings, and vaccines aimed at preventing illness.

10. Pediatric ServicesFor those with children, pediatric services like dental and vision care are usually covered, but the extent can differ.

ConclusionIt’s essential to read your policy’s fine print to understand what is covered and what isn’t. Just because a service is listed as an “Essential Health Benefit” doesn’t mean it’s fully covered without any cost-sharing like copays or deductibles. If in doubt, consult your insurer or a healthcare advisor to clarify the specifics, ensuring you’re making informed decisions about your healthcare needs.